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2022 exceptional surveillance of venous thromboembolism in over 16s (NICE guideline NG89)

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Surveillance proposal

We will not update the guideline on Venous thromboembolism in over 16s (NG89) on VTE prevention.

Reasons for the proposal

A new trial [GAPS trial (Shalhoub et al 2020)] compared a combination of low molecular weight heparin (LMWH) plus anti-embolism stockings (AES) versus LMWH and found LMWH to be non-inferior in venous thromboembolism (VTE) reduction at 90 days post-surgery. This trial recruited non-orthopaedic, elective surgery patients. Patients with some of the highest risk factors for VTE (such as a history of VTE or thrombophilia); or with certain features in the procedure or history requiring them to have extended prophylaxis were excluded. This trial did not stratify or conduct subgroup analyses based on different types of surgical procedures.

The trial's findings do not affect the current recommendations. The guideline recommends considering either a pharmacological prophylaxis or a mechanical prophylaxis as an alternative if there are bleeding risks for the surgical procedure. The option of using both a mechanical and pharmacological prophylaxis, rather than only one type of prophylaxis is limited to certain circumstances.

For patients undergoing bariatric or other procedures in the abdominal area, the recommendation was to start a mechanical prophylaxis on admission. If an individual patient has VTE risks which outweigh the risk of bleeding, a pharmacological option such as LMWH should be offered as an additional prophylaxis method. A similar approach is recommended for procedures where the risk of bleeding is important (cranial, spinal, thoracic, or cardiac surgery), except that the recommendation is to "consider" rather than "offer" these options. The choice of wording used reflected the strength of the evidence base supporting the recommendations and emphasised balancing the risks of VTE and bleeding in individual patients.

As the NICE VTE prevention guideline limits the use of combination prophylaxis to specific circumstances, it will not be necessary to update the guideline. The new evidence does not provide evidence to support the replacement of mechanical prophylaxis with pharmacological prophylaxis.